Medford Volunteer Fire Fighter ApplicationPersonal InformationFirst Name *Middle NameLast Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Date of Birth *0 / 10Phone Number *EmployerEmployer AddressOccupationEmployer Phone NumberEmergency ContactFirst Name *Middle NameLast Name *Phone Number *Medical & Legal InformationDriver’s License Number *License Class *Do you have any physical limitations? (Yes/No) *YesNoIf yes, please explain *Physician or Family DoctorPhysician Phone NumberPhysician AddressHave you ever been convicted of a felony? *YesNoIf yes, please explain. *Reference (Non-Family)First Name *Last NamePhone Number *Relationship *Years Known *CertificationI certify that all statements made in this application are true and correct to the best of my knowledge.Applicant Signature *Date **Medford Volunteer Fire Department performs background checks on all applicants*CheckboxFundraiser SupportScene SupportWildland FirefighterDriver OperatorExterior FirefighterInterior FirefighterUnsure/UnknownSubmitPlease do not fill in this field.
